Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fondulac Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with multiple traumatic injuries, cervical spinal fusion, immobility, and pain medication orders was left waiting in a wheelchair while in pain, left suspended in a mechanical lift sling during a transfer, and left in stool after pressing the call light. The resident’s chart also showed delayed admission assessment, only one set of VS after admission, and multi-day gaps in pain assessments despite repeated moderate to severe pain.
Failure to Provide Hair Care and Grooming Services: A resident with MS, incomplete paraplegia, ataxia, and total ADL dependence was observed with matted, tangled hair under a head covering. The resident became tearful and embarrassed, stating no one came to fix her hair and she could not braid it herself. Staff said CNAs were limited in what they could do, there was no beautician available, and the facility did not have a current beautician contract; the care plan did not address hair care or grooming needs.
A resident with multiple fractures, cervical spinal fusion, immobility, and pain meds had repeated moderate-to-severe pain documented, but pain assessments were missed for multiple days despite a policy requiring them every shift. Staff did not timely assess or intervene when the resident was left in a wheelchair in pain after the call light went unanswered, and the resident was also left suspended in a mechanical lift sling while beds were switched, with family reporting neck pain, numb legs, and yelling for help. Interviews confirmed missing vitals, delayed admission assessment, and no documented pain monitoring during these events.
A facility failed to ensure residents and family members had reasonable access to phone communication. Family members reported repeated unanswered calls, long holds, and no way to leave messages, while a resident stated he could not get staff to answer when he called for help. The administrator said daytime calls were handled by Medical Records and after-hours calls by clinical staff, but there were no cordless phones, no full-time receptionist, and no voicemail box, and staff reported dozens of missed calls.
A resident in pain remained in a wheelchair waiting to return to bed while his call light went unanswered for an extended period. The resident reported no response to his call light or the facility phone, and his family member said the DON told her he would have to wait because he needed a 2-person transfer and a CNA was on break. The record did not show a pain assessment, pain intervention, or timely assistance back to bed, despite the facility policy requiring call lights to be answered promptly and efficiently.
Failure to document resident belongings at discharge. A resident with a compression fracture and low back pain had a wheelchair and STS back brace noted in the record, but nursing notes did not document personal inventory items sent at discharge or follow-up calls with the POA. The POA reported the wheelchair and brace could not be located, and the DON confirmed there was no inventory sheet or progress note documentation for the resident’s personal items.
Incomplete resident-specific care planning and monitoring: A resident admitted after a motorcycle accident with multiple traumatic injuries, cervical fusion, dysphagia, chronic pain, and mobility restrictions had repeated severe pain scores and gaps in pain documentation, with only one set of VS recorded after admission. The care plan addressed orthopedic restrictions but did not comprehensively include pain management, VS monitoring, call light response, toileting assistance, or safe mechanical lift transfers; the DON confirmed the missing pain and VS documentation. Another resident’s care plan also lacked comprehensive resident-specific problems, goals, and interventions.
Incomplete fall investigation and unsafe mechanical lift transfer: A resident with epilepsy, seizures, foot drop, and other diagnoses fell when a wheelchair tipped backward during staff assistance, but the fall investigation and nursing record lacked key details such as injury description, mental status, pain level, environmental factors, and witness interviews. Another resident with multiple fractures, cervical spinal fusion, immobility, and pain was left suspended in a mechanical lift sling for about 15 minutes while staff switched beds, despite policy requiring safe transfer to the designated surface and prompt repositioning.
Torn Mattress Left in Resident Room: A resident’s bed mattress was observed with punctures exposing internal materials and with dips and lumps on the sleeping surface while the bed was unmade. The resident said staff had known about the mattress for over a year and that it was very uncomfortable. The HSKP supervisor said staff usually report worn mattresses, and the administrator said new mattresses had been ordered but was unsure how this one was missed.
Failure to maintain clean and sanitary resident areas was identified after surveyors observed dirt, debris, sticky floors, urine odors, missing bed linens, overflowing trash, and fecal smears in resident rooms, hallways, and bathrooms. A resident reported the facility never sweeps and only mops over debris, another resident described a shared bathroom that was not cleaned daily, and a third resident had urine-soaked linens and an adult brief left on the floor after incontinence care. Staff and the housekeeping director acknowledged that rooms and floors were not being kept as clean as they should be, and soiled linens and briefs were placed on the floor instead of in a protective bag.
A resident with chronic respiratory failure, venous insufficiency, and DM2 was discharged home without documented discharge planning, discharge assessment, or a recapitulation of stay. A CNA left the resident’s belongings and medical supplies on the porch, and the resident later reported no running water, no food, and no home health support. The DON and SSD confirmed no home health or safety screening was completed, and the MD stated he had ordered home health for the discharge.
Inaccurate Fall Assessments and Unsafe Shower Supervision The facility failed to complete accurate fall risk assessments, document post-fall follow-up, and assess the safety of residents who showered independently. A resident with no fall care plan or fall risk assessment before admission fell and fractured a hip, and another resident was left alone in the shower, fell, and fractured an arm. Staff also confirmed that several residents were treated as independent shower residents without documented requests, safety assessments, or care plan interventions, and one post-fall record lacked a physical assessment and required 72-hour monitoring.
Inaccurate care plan entries were documented for a resident who was cognitively intact and made his own decisions. The care plan included behavior and mental status focus areas such as false accusations, refusal of showers, delusional thoughts, and believing staff were against him, but the DON and LPN could not provide any investigation or supporting documentation for these claims and confirmed neither had investigated any accusations made by the resident.
A cognitively impaired, nonverbal resident with multiple diagnoses was sexually abused on more than one occasion by another resident. Staff witnessed and reported the incidents, but administration failed to provide guidance, implement safety interventions, or ensure required assessments and notifications were completed. Both residents' care plans lacked appropriate interventions, and the facility did not follow its abuse prevention policy.
A cognitively impaired resident with multiple medical conditions exited the facility unsupervised through an unsecured smoking patio door after staff failed to follow elopement protocols, including conducting a head count when a door alarm sounded. The resident was later found over two miles away in the dark and cold. Additionally, another high-risk resident was not provided with required electronic monitoring or one-on-one supervision, despite care plan directives.
Staff failed to immediately report and investigate an incident where a resident was witnessed sexually abusing another resident on two occasions. Despite being informed, the administrator in training did not notify the state agency, law enforcement, or the resident's representative, and the alleged perpetrator continued to have unsupervised access to other residents, violating the facility's abuse reporting policy.
Two CNAs witnessed a resident sexually assaulting another resident on two occasions, but the facility failed to investigate, implement protective interventions, or report the incident to the state agency. The alleged perpetrator continued to have unsupervised access to all residents, and no increased supervision or safety measures were documented in the medical records.
The facility failed to employ a licensed administrator, resulting in the lack of investigation and reporting of a witnessed sexual abuse incident between two residents. Staff did not receive required annual in-service trainings, and multiple staff members reported that the acting administrator attempted to cover up the abuse, altered witness statements, and did not notify authorities or provide direction to protect residents.
The facility did not provide required annual QAPI in-service training to all staff, as confirmed by the DON and review of facility records. This deficiency had the potential to affect all 79 residents currently residing in the facility.
The facility did not provide required annual infection control and prevention training to its staff, as confirmed by the DON, despite having 79 residents in care and a scheduled training on the in-servicing calendar.
The facility did not provide annual Compliance and Ethics in-service training to any staff, as confirmed by the DON, despite the training being scheduled. This affected all staff while 79 residents were present in the facility.
All staff did not receive the required annual behavioral health in-service training, as confirmed by the DON and documented in facility records. This lapse could impact all 79 residents in the facility.
A resident with multiple health conditions sustained a deep leg laceration requiring hospital treatment after a CNA failed to ensure the resident's legs were clear before repositioning their wheelchair. The facility's policy on skin condition monitoring was not followed, and the CNA was terminated for poor performance.
A resident with Type Two Diabetes Mellitus and Diabetic Chronic Kidney Disease did not receive physician-ordered insulin, leading to emotional distress and abnormal lab values indicating hyperglycemia. The facility's records showed numerous instances of missed insulin administrations and blood glucose checks. The resident's Hemoglobin A1C was significantly higher than the physician's target, and the physician noted that the lack of insulin and monitoring could have contributed to this.
The facility failed to serve foods as written on the menu, affecting all 63 residents. The menu listed specific items, but residents received different foods. The Dietary Manager was unaware of the reasons for substitutions and attributed it to a new cook. Residents complained about frequent menu discrepancies, and the substitution book lacked proper documentation and Dietitian sign-off.
The facility failed to maintain proper food safety and sanitation practices, affecting all 63 residents. Unlabeled and undated food items were found in the resident refrigerator, and a cook improperly mixed a chlorine solution, resulting in a poisonous concentration. Additionally, unsanitary conditions were observed in the kitchen, and pre-cooked chicken was placed on the steam table hours before serving. The Dietary Manager and DON confirmed these issues, indicating a lack of adherence to facility policies.
The facility did not have an RN on duty for eight consecutive hours on four days in July 2024, as confirmed by the Assistant DON. This staffing gap was contrary to the facility's assessment plan to ensure sufficient staffing for its 63 residents.
The facility failed to perform proper hand hygiene during medication administration and did not implement Enhanced Barrier Precautions (EBP) to prevent the spread of MDROs. An LPN was observed handling medications and administering insulin without gloves or hand hygiene. Additionally, staff were not following EBP protocols for residents with indwelling devices or open wounds, and there was a lack of awareness and implementation of EBP throughout the facility.
The facility failed to notify residents, their representatives, and the Ombudsman of hospital transfers. Several residents were transferred multiple times without written notices, and the Social Services Director and Administrator confirmed the lack of notifications. This deficiency could impact all 47 residents.
The facility failed to provide the required bed hold policy notice to four residents upon their transfer to a hospital, as mandated by their policy. This deficiency was confirmed by the Social Services Director and the facility administrator, who acknowledged the oversight.
The facility failed to develop comprehensive care plans for four residents regarding their use of anticoagulants and psychotropic medications, as well as target behaviors for one resident. The Care Plan Coordinator and Assistant Director of Nursing confirmed the absence of these care plans, indicating a failure to meet the facility's policy of developing person-centered care plans.
The facility failed to perform the required nurse shift-to-shift controlled substance reconciliation for 19 residents receiving controlled substances. The facility's policy requires Schedule II drugs to be counted and reconciled by the incoming and outgoing nurses, with records retained for at least one year. However, documentation was missing for specific dates, as confirmed by an LPN and the DON, indicating a lapse in policy adherence.
A resident reported that an LPN deliberately delayed medication administration, causing distress. Despite the resident's complaints to the administration, the facility failed to report the alleged mental abuse to the state agency, violating their abuse prevention policy.
A resident alleged mental abuse by an LPN, claiming the nurse withheld medications and laughed about it. Despite the facility's policy to remove accused employees from resident contact, the LPN was not removed, and no formal abuse investigation was conducted. The resident, who was cognitively intact, expressed distrust and refused medications from the LPN, leading to the ADON administering them instead.
The facility failed to complete PASARR screenings for three residents with mental disorders or intellectual disabilities. One resident with Schizophrenia and Psychosis had no PASARR Level I documentation. Another resident, admitted with Schizophrenia, did not receive a required follow-up PASARR after 60 days. A third resident with Bipolar Disorder lacked any PASARR documentation. The ADON confirmed these deficiencies.
The facility failed to perform physician-ordered daily skin checks and scheduled pressure ulcer treatments for three residents, and did not develop a care plan for one resident's pressure ulcers. A resident with spastic cerebral palsy and other conditions missed 10 out of 17 skin checks, while another with multiple health issues missed 3 out of 7. A third resident with pressure injuries had missed treatments and lacked a care plan, with staff confirming documentation gaps.
An LPN failed to perform hand hygiene between glove changes while providing suprapubic catheter care to a resident with Neurogenic Bladder and Obstructive Uropathy. This breach in infection control practices occurred despite the resident's history of urinary tract infections and a care plan aimed at preventing such infections.
A facility failed to ensure a licensed pharmacist conducted monthly drug regimen reviews for a resident over six months. Despite the facility's policy requiring monthly meetings with a consultant pharmacist for potential medication reductions, the resident's medical record showed no reviews from March to August. The DON confirmed only one review was completed in February.
The facility failed to document diagnoses and target behaviors for the use of antipsychotic medications for three residents. One resident was on Seroquel without a documented diagnosis or behaviors justifying its use. Another resident, despite having schizophrenia, had no documented target behaviors or dose reduction attempts for Clozaril. A third resident was on multiple psychotropic medications without recent dose reductions, despite recommendations. Observations showed minimal adverse behaviors, and staff were unaware of justifications for the medications.
A resident with multiple serious conditions did not receive physician-ordered lab tests, including a CMP and CBC, due to staff oversight. The DON confirmed the lapse in ordering the necessary tests.
Delayed Care, Pain Assessment Gaps, and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure one resident received necessary care and services to maintain his highest practicable physical, mental, and psychosocial well-being after admission following a motorcycle accident with multiple traumatic injuries. The resident’s records documented cervical spinal fusion, multiple fractures, mobility restrictions, braces/splints, anticoagulation therapy, pain medications, chronic pain syndrome, and inability to use his arms. He was documented as alert, able to make needs known, and independent with decision making, but required extensive staff assistance due to non-weight-bearing restrictions, immobility, and pain. Survey findings showed the resident was left waiting in his wheelchair while in pain and wanting to return to bed, with his call light on for an extended period and no documented timely assessment or intervention to relieve the pain. The record did not show that he was promptly assisted back to bed. The resident also reported that, during an early transfer after admission, staff used a mechanical lift and left him suspended in the sling for approximately 15 minutes while beds were switched, with no staff present during that time. A family member and a family friend corroborated that he was left suspended in the sling, was in obvious pain, and that no nursing assessment, vital signs, or pain medication were provided while they were present. The facility also failed to provide timely toileting/incontinence care. The resident stated that on another occasion he had a bowel movement, pressed his call light, and remained in stool for over two hours before receiving help, which he described as humiliating and disgusting. Records and interviews showed the resident was continent of bowel and able to communicate his needs, yet assistance was delayed. In addition, the admission nursing assessment was not completed in a timely manner, and the resident had only one documented set of vital signs after admission despite his recent hospitalization, multiple fractures, spinal fusion, pain medication use, anticoagulant use, immobility, and need for skilled nursing observation. Pain assessments also had multi-day gaps despite repeated moderate to severe pain scores and standing pain medication orders.
Failure to Provide Hair Care and Grooming Services
Penalty
Summary
The facility failed to ensure necessary grooming, hair care, personal hygiene, and personal appearance services were provided for one resident, R12, who was reviewed for quality of care. R12 was admitted with primary progressive multiple sclerosis, incomplete paraplegia, disorder of muscle, ataxia, cognitive communication deficit, chronic pain, heart failure, and protein-calorie malnutrition. Her care plan documented that she needed staff assistance with bathing, total assistance with personal hygiene care, was bedfast most of the time, and required a mechanical aid for transfers, but it did not include a focus, goal, or intervention for hair care, grooming assistance related to hair, personal appearance preferences, beautician/barber services, or monitoring and prevention of matted or tangled hair. During observation, R12 was seen in bed wearing a head covering while receiving incontinence care and bathing. Her hair was observed to be matted and tangled under the covering. R12 appeared upset and tearful when discussing her hair and stated that this should not be happening, that no one comes to fix her hair, and that she has to wear a covering to hide it. She stated she did not like her hair like that, was embarrassed and did not want to be seen looking that way, and could not braid her own hair because only one hand works. Interview findings showed V17/CNA said she used to braid R12's hair but was told not to because she was not licensed, and that there was no beautician coming to the facility anymore. V17 also stated another CNA who is licensed does residents' hair sometimes, but staffing prevents her from doing it as often as needed. V2/DON stated the facility had not been able to find a beautician for years, and V1/Administrator stated the facility did not have a contract with a beautician at that time. The facility's Resident Rights policies and Beautician/Barber Policy stated residents have the right to dignity, quality of life, and access to grooming and personal appearance services, but R12 did not receive timely hair care or grooming consistent with those requirements.
Failure to Assess and Relieve Severe Pain During Transfers and Care
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with multiple traumatic injuries, cervical spinal fusion, chronic pain syndrome, immobility, and prescribed pain medications. The resident was admitted after a motorcycle accident with multiple fractures and mobility restrictions, including non-weight bearing status to several extremities and use of braces/splints, therapy, and a CPM machine. The record showed ongoing moderate-to-severe pain, with documented pain scores including 9/10, 7/10, and 10/10, but there were multi-day gaps without documented pain assessments despite the facility policy requiring pain assessments at least every shift. The record and interviews showed the resident was not timely assessed or assisted when reporting pain during care and transfers. On one occasion, the resident’s mother reported the call light had been on for 40 minutes while the resident was in pain and wanted to return to bed, but the chart did not show a pain assessment, intervention, or timely transfer back to bed. The resident later stated he pressed the call light with no response, tried calling the facility, and then contacted a family member for help. The family member reported the resident had been left in a wheelchair in pain for over an hour and that staff said he had to wait because a CNA was on break. Additional interviews described the resident being left suspended in a mechanical lift sling for about 15 minutes while staff switched beds in a new room. The family member and a family friend stated the resident complained of neck pain, his legs were going numb, and he was yelling for help while no one was around. Staff interviews confirmed the resident was not assessed at admission as required, with one RN stating she did not complete vital signs or assessments because she was busy entering medication orders, and the DON stating there was nothing in the care plan or orders about pain or vital signs and that assessments were not being completed as expected.
Telephone Access and Call Response Failures
Penalty
Summary
The facility failed to ensure residents had reasonable access to telephone communication and privacy in their use of communication methods for four residents reviewed for telephone communication. Family members and residents reported repeated difficulty reaching the facility by phone, including calls that rang without answer, calls that were not returned, and long holds when calls were answered. One resident stated he had tried to call the facility for help and could not get anyone to answer, and a family member reported the resident had to call her so she could contact the building to reach staff. The administrator stated he had been made aware about a month earlier of an issue involving a resident's family member being unable to get through after hours. Medical Records answered phones during weekday daytime hours, while clinical staff, including nurses and CNAs, were responsible after hours. The facility had no mobile or cordless phones, only phones at nurse's stations and in offices, no full-time receptionist, and no voicemail box set up for callers to leave messages. The Medical Records/Receptionist staff member stated there were times she arrived to find 50 or more missed calls on the phone and that family members sometimes reported they could not get anyone after she left for the day.
Delayed response to resident call light and transfer request
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner and failed to follow its Call Light Policy for one resident. The resident was in a wheelchair, in pain, and wanted to return to bed after being up in the chair for the first time following a wreck, injuries, and hospitalization. According to the nursing progress note, the resident's mother reported the call light had been on for 40 minutes and the resident was waiting to be put back in bed. The note documented that the CNA was waiting for someone from another hall to assist with the transfer, but it did not show an assessment of the resident's pain level, any intervention to relieve pain, or documentation that the resident was timely assisted back to bed. The resident stated he pressed the call light with no response, tried calling the facility with no answer, and then called his family member for help. The family member stated the resident told her his call light had been on for over an hour while he remained in his wheelchair in pain, and that he could not get through to the facility when he tried to call. The family member contacted the DON, who told her the resident would have to wait because he required two people for transfer and one CNA on the hall was on break. The DON stated she told the nurse and CNA caring for the resident that shift and assumed they would take care of it. The facility policy required call lights to be answered in a timely and efficient manner based on urgency, and the CNA job description included answering call lights promptly and assisting residents with daily needs and transfers.
Failure to Document Resident Belongings at Discharge
Penalty
Summary
The facility failed to verify and document personal inventory items for one resident, R3, who was reviewed for discharge. R3’s record showed admission with diagnoses including Compression Fracture of the T11-T12 Vertebrae and Low Back Pain, and an order for a Shoulder-Thoracic-Sacral back brace. Nursing progress notes documented that R3 was in the hospital and later that the sister/POA decided to have R3 admitted to another facility closer to her, but the nursing notes from the period reviewed did not document that R3’s personal inventory items or belongings were sent at discharge and did not document follow-up telephone calls with the sister/POA. The sister/POA stated that after R3 went to the hospital and did not return to the facility, she went to the facility to collect belongings and could not find the wheelchair or back brace. She also stated that the new facility called the old facility about the wheelchair and back brace and was told they did not have them. The Administrator stated the facility believed the wheelchair and back brace had been taken by the sister/POA because they could not locate those items, and the DON stated there was no inventory sheet for R3 and no documentation in the progress notes regarding personal items. The facility policy required the nurse to document what belongings were sent with the resident and required Social Services or designee to complete a post-discharge follow-up call and document the outcome.
Incomplete resident-specific care planning and monitoring
Penalty
Summary
The facility failed to develop and revise comprehensive, person-centered care plans for three residents reviewed for comprehensive care plans. For one resident admitted after a motorcycle accident with cervical spinal fusion, multiple fractures, dysphagia, chronic pain syndrome, stiffness of the right shoulder and elbow, muscle wasting and atrophy, and lack of coordination, the record showed ongoing moderate to severe pain with repeated scores as high as 10 out of 10 and multi-day gaps in pain documentation. The resident’s chart also showed only one set of vital signs documented after admission, with no additional blood pressure, temperature, pulse, respirations, or oxygen saturation monitoring recorded through the review period. The resident’s care plan addressed orthopedic restrictions such as weight-bearing limits and brace/splint use, but did not comprehensively address pain assessment and management, vital sign monitoring needs, timely call light response and assistance needs, toileting/continence assistance needs, or safe mechanical lift transfer needs. For another resident, the care plan included elopement, cognition, and therapeutic leave focus areas, but the report states the care plan did not comprehensively address resident-specific problems, goals, and interventions. The DON stated there was nothing in the first resident’s care plan or orders about pain or vital signs and confirmed the resident had no documented vital signs since admission and gaps in pain assessments.
Incomplete fall investigation and unsafe mechanical lift transfer
Penalty
Summary
The facility failed to complete and document a fall investigation for a resident who struck his head after his wheelchair tipped backward while staff were assisting with clothing caught in the wheelchair wheel. The resident had a history of epilepsy, seizures, depressive disorder, bilateral foot drop, panic disorder, lumbar radiculopathy, and a wedge compression fracture of T11-T12. The fall investigation report documented that the resident hit his head on the floor and had a bump on the back of his head, but the report was not fully completed and did not include mental status, injury description, pain level, predisposing environmental factors, predisposing situation factors, or witness/staff interviews. Nursing documentation for the fall did not include monitoring of the head injury’s size, color, or exact location, and the record did not identify the staff present during the event. The resident was documented as having a change in condition and increased head pain, was given pain medication, and was sent to the emergency department. The resident’s sister/POA was documented as notified in the fall report, but the RN stated she did not remember whether she notified her, and the sister stated she was not notified by the facility and learned about the incident from the resident later. The facility also failed to follow its mechanical lift and safe lifting policies when staff transferred another resident with multiple traumatic injuries, including cervical spinal fusion, multiple fractures, limited upper-extremity use, immobility, and pain. Staff used a mechanical lift to move the resident from a wheelchair, then left the resident suspended in the sling for about 15 minutes while they switched beds in the room. The resident and family witnesses stated the resident was left in the air without staff present, complained of neck pain, and appeared to be in obvious pain, while the DON stated residents should not be left suspended in a mechanical lift unattended or for prolonged periods.
Torn Mattress Left in Resident Room
Penalty
Summary
The facility failed to maintain environmental equipment safety, comfortability, and appearance for one resident’s bed mattress. During observation, the resident was sitting in a wheelchair while the bed was unmade, and the exposed blue mattress had a moderate amount of brown/tan punctures on the outer layer that exposed internal mattress materials. Dips and lumps were also noted on the sleeping surface. The resident stated that staff had known about the mattress for over a year, that it looked terrible, and that it was very uncomfortable. The housekeeping supervisor stated that staff usually notify him when mattresses are dirty or worn and that nursing staff, housekeeping staff, and maintenance usually work together when they see a mattress that needs to be changed. The housekeeping supervisor later entered the room and exchanged the mattress after overhearing the resident’s comments. The administrator stated that new mattresses had been ordered and was not sure how this mattress had been missed. The resident rights documents cited in the report state that residents have the right to dignity, respect, quality care, and services or items included in the plan of care.
Failure to Maintain Clean and Sanitary Resident Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary environment by not keeping resident rooms, bathrooms, hallways, and common areas clean and orderly. During the initial tour, the front entrance, dining room, and main nurses’ station floors were observed with dirt, debris, and a sticky substance that adhered to shoes. Hall A, Hall B, and Hall C all had dirt, debris, and sticky substances on the hallway floors and in resident rooms, and several rooms had urine odors. Multiple resident rooms were missing bed sheets, some trash cans were overflowing or missing liners, and one room contained urine-soaked bed sheets and an adult brief saturated with urine on the floor. One shared bathroom had brown smears on the floor and around the toilet area with a strong fecal odor. Resident observations and interviews described ongoing cleaning problems in the facility. One resident stated the facility never sweeps, mops sometimes go over crumbs and debris, the room smells like urine, and trash is only removed when asked. Another resident was observed in a cluttered room with empty bowls, food wrappers, a full trash can, a urine container, dirt and debris on the floor, and a shared bathroom with fecal smears and odor; that resident stated the bathroom was not cleaned daily and the room was usually cleaned only three to four days per week. A third resident was observed with urine-soaked bed sheets and an adult brief on the floor after incontinence care, and the resident stated staff did not mop the floor after cleaning up the soiled items. Staff interviews confirmed that soiled linens and briefs were placed on the floor instead of in an enclosed protective bag, and that bodily fluids around toilets were expected to be cleaned promptly and then disinfected. Housekeeping staff and the housekeeping director acknowledged that rooms and floors were not being kept as clean as they should be and that this had been a problem for some time. The facility’s housekeeping and CNA job descriptions required cleaning, disinfecting, sweeping, mopping, removing trash, making beds, and handling linens according to infection control guidelines, and the infection prevention policy stated resident rooms would be clean and orderly.
Failure to Complete Discharge Planning and Safe Transition
Penalty
Summary
The facility failed to follow its own discharge policy for one resident who was discharged home without documented discharge planning, discharge assessment, recapitulation of stay, or documentation addressing the disposition of belongings and medications. The resident’s medical record showed diagnoses including chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, and type II diabetes mellitus, and also documented that he was cognitively intact and made his own decisions. His last care plan indicated that long-term stay in the facility was anticipated. Surveyor interview and record review showed that the resident was transported home by a CNA, who placed all of his belongings, including medical supplies, on the front porch. The CNA stated she did not believe the resident could move the belongings inside by himself. The resident later called police because his belongings were outside in the rain, and the social services director at the local police department reported that the resident’s bandages were ruined, the home had no running water or food, and there was no home health, friends, or family to assist him. The resident stated he had been promised home health help but did not receive it. The DON confirmed that no home health was set up and no safety screening or questions were completed with the resident, and the social services director confirmed she did not arrange home health assistance. The medical director stated he had ordered discharge home with home health and that all conditions for safety must be met before a resident is left alone after discharge. The facility administrator also confirmed there was no documentation of discharge planning or any indication of the resident’s discharge home and date of discharge.
Inaccurate Fall Assessments and Unsafe Independent Showering
Penalty
Summary
The facility failed to ensure residents had accurate fall risk assessments, fall care plans, and post-fall follow-up documentation, and it failed to provide adequate supervision for residents who were showering independently. The report states that the facility also failed to assess the safety of residents who requested to shower alone for multiple residents. These failures were identified through interview and record review and were associated with falls and injuries, including one resident who fell and fractured a hip and another resident who fell in the shower and fractured an arm. One resident was admitted after a pacemaker placement and was documented as alert and able to make her own health care decisions. Her record did not contain a care plan or fall risk assessment until after she fell on the hallway floor and was sent to the hospital, where she required surgery to repair a broken right hip. The nurse and care plan coordinator confirmed there was no fall risk assessment or fall prevention care plan in place before the fall, and the director of nursing confirmed the assessment and care plan should have been present on admission. A family member stated the facility did not seem ready for the resident when she arrived and did not see fall precautions in place before the fracture occurred. Another resident was admitted with diagnoses including type II diabetes mellitus, Crohn’s disease, and chronic atrial fibrillation and was documented as alert and able to make his own decisions. The facility’s investigation showed he was left alone in the shower because staff believed he preferred to shower alone. A CNA stated she left him unsupervised because he said he did not have anyone with him when he showered. The resident’s record did not contain documentation of a request to shower alone, a safety risk assessment, or education about the risk of falling if left unsupervised. He later stated he was alone in the shower when he fell and broke his arm. The report also identified inaccurate fall risk data collection for other residents. One resident’s fall risk assessment did not reflect medications documented on the MAR, including metformin, hydrocodone, and trazodone, and the LPN/CPC confirmed those medications should have increased the fall risk score. Another resident’s fall risk assessment did not reflect medications including Lasix, olanzapine, and metoprolol, and the DON confirmed the assessment was marked incorrectly. For one resident who was found on the floor with a raised area on the forehead, the record lacked a documented physical assessment and lacked the required post-fall monitoring for 72 hours. The report also states that several residents were considered independent shower residents, but the facility had no documented request to shower alone, safety assessment, or care plan interventions for them.
Inaccurate Care Plan Entries
Penalty
Summary
The facility failed to ensure the accuracy of R5’s care plan. R5 was admitted with diagnoses including Chronic Respiratory Failure with Hypoxia, Type II Diabetes Mellitus, and Chronic Peripheral Insufficiency, and the medical record documented that he was cognitively intact and made all of his own decisions. Despite this, the care plan dated 3/9/26 included focus areas stating that R5 had a behavior problem related to false accusations, refused showers and would tell other staff no shower was offered, had mood problems, had delusional thoughts, believed everyone was against him, and thought staff were calling him a liar if they disagreed with him. These care plan entries were entered by the DON, who later denied knowledge of the focus areas, stating she had to sign a lot of care plans. The LPN/Care Plan Coordinator stated she initiated the entries but could not provide any investigation or supporting documentation of R5 making false accusations, and both the DON and LPN confirmed that neither had ever investigated any accusations made by R5. The LPN stated she was told by staff that R5 lies.
Failure to Protect Resident from Sexual Abuse and Inadequate Response
Penalty
Summary
The facility failed to protect a cognitively impaired resident from repeated sexual abuse by another resident who was cognitively intact. On two separate occasions during breakfast, staff observed the perpetrating resident sitting next to the victim, with their hand between the victim's legs, touching the victim's vagina. Despite staff intervening and verbally instructing the perpetrator to stop, the inappropriate contact recurred within a short period. The staff reported the incident to the Administrator in Training, who did not come to the facility, did not provide guidance, and did not implement safety interventions to prevent further abuse. The victim was severely cognitively impaired, nonverbal, and had diagnoses including cerebral palsy, intellectual disabilities, anxiety, and depression. The victim's care plan did not include interventions to prevent sexual abuse, and there was no documentation or assessment of the victim following the abuse. Additionally, a trauma care assessment was not completed after the incident, and the victim's guardian was not notified of the allegation. The perpetrator's care plan also lacked interventions addressing sexual behaviors, and there was no documentation of the abuse allegation in the perpetrator's medical record. The facility's abuse prevention policy required immediate steps to prevent further abuse, assessment of the resident, notification of the physician and responsible party, and completion of a trauma-informed care assessment. These steps were not followed after the incident, as the staff did not receive direction from administration, and the required assessments and notifications were not completed. This failure resulted in an Immediate Jeopardy situation due to the lack of protection and appropriate response to resident-to-resident sexual abuse.
Failure to Prevent Elopement and Provide Adequate Supervision for At-Risk Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risk. A cognitively impaired resident with multiple diagnoses, including chronic obstructive pulmonary disease, hemiplegia, diabetes, and depression, was assessed as a moderate risk for elopement and had a history of exit-seeking behavior. Despite these known risks, the resident's care plan did not include interventions to address elopement until after the resident had already left the facility without staff knowledge or supervision. The resident was able to exit through a smoking patio door, which was not kept secure, and the door alarm was dismissed by staff without a resident head count or further investigation, as required by facility policy. The incident occurred when the resident exited the facility during the night and was later found 2.2 miles away, standing on a concrete median by a stop light in the dark, expressing that he was cold. Staff interviews revealed that the nurse on duty heard the door alarm but assumed it was triggered by the wind and did not follow procedures to account for all residents, particularly those at risk for elopement. The resident was not discovered missing until several hours later when another staff member found him outside the facility. The resident required a walker, had impaired cognition, and was not safe to be outside unsupervised, especially at night and in cold weather. Additionally, another resident identified as high risk for elopement was observed without the required electronic sensor device or one-on-one supervision, despite care plan directives. Staff confirmed that this resident had not been provided with the necessary monitoring devices or supervision. The facility's elopement policy required immediate response to door alarms, investigation of the cause, and accounting for all at-risk residents, but these procedures were not followed, contributing to the deficiencies identified.
Failure to Report and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedures by not immediately reporting and investigating an incident of resident-to-resident sexual abuse. Two certified nursing assistants witnessed a resident placing their hand up another resident's shorts and touching the resident's vagina on two separate occasions. The first incident was not reported to the administrator, and only after the second incident did the nursing assistants inform the LPN, who then contacted the administrator in training. Despite these reports, the administrator in training did not notify the state agency, local law enforcement, or the resident's representative as required by the facility's policy. During the period following the incident, the resident who committed the abuse continued to have unsupervised access to all other residents in the facility. The facility's policy mandates immediate reporting of all abuse allegations to the administrator, state agency, and law enforcement, with a summarized investigation to be completed within five business days. However, the administrator in training confirmed that no report was made to the required authorities regarding the witnessed sexual abuse, resulting in a failure to protect residents and comply with mandated reporting requirements.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure in response to an allegation of resident-to-resident sexual abuse. Two certified nursing assistants witnessed one resident placing their hand up another resident's shorts and touching the resident's vagina on two occasions. Despite this, the administrator in training confirmed that no investigation was conducted, and no report was submitted to the state agency. The electronic medical records for both residents did not include any interventions or increased supervision to protect the affected resident or others from further abuse. Additionally, the alleged perpetrator continued to have unsupervised access to all residents in the facility following the incident. Staff interviews revealed that the administrator was made aware of the allegations but did not provide any immediate safety interventions and delayed the start of the investigation. Observations showed the alleged perpetrator moving freely throughout the facility and in proximity to the victim after the incident. The facility's abuse policy requires immediate reporting, thorough investigation, protective measures, and timely submission of a final report to the state agency, none of which were followed in this case.
Unlicensed Administrator and Failure to Investigate and Report Abuse
Penalty
Summary
The facility failed to employ a licensed administrator, as required, to ensure the protection of all residents from abuse, proper investigation and reporting of abuse allegations, and the provision of mandatory staff training. The individual acting as Administrator was hired without evidence of a bachelor's degree or a temporary or permanent administrator's license. This individual admitted to not having the required qualifications and did not receive a temporary license at any time during their tenure. The facility's records also showed that staff did not receive required annual in-service trainings, including the 12-hour CNA training, QAPI, behavioral health, infection control, and compliance and ethics program trainings. Multiple staff members reported that the acting administrator failed to investigate and report a witnessed incident of sexual abuse between two residents. Staff described the administrator as attempting to minimize or cover up the incident, altering witness statements, and failing to notify the state agency, police, or resident representatives. Staff also reported a lack of direction from the administrator regarding the separation of the involved residents. The Director of Nursing confirmed the absence of required staff trainings, and several staff members expressed concerns about the administrator's truthfulness and intimidating behavior.
Failure to Provide Annual QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program to all staff, as required by its own policy. Record review showed that the annual in-servicing calendar specified QAPI training for all staff in March, but verification by the Director of Nursing confirmed that no staff had received this training for the current year. At the time of the survey, 79 residents were documented as residing in the facility, and this lack of training had the potential to affect all of them. The deficiency was identified through both record review and staff interview.
Failure to Provide Annual Infection Control Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received annual in-service training on Infection Control and Prevention as required by its infection prevention and control program. Record review showed that the facility's annual in-servicing calendar scheduled infection prevention and control training for all staff in April. However, as verified by the Director of Nursing, no staff received this training. At the time of the survey, 79 residents were residing in the facility.
Annual Compliance and Ethics Training Not Provided to Staff
Penalty
Summary
The facility failed to ensure that all staff received annual Compliance and Ethics in-service training. Record review showed that the in-service calendar scheduled this training for all staff in April, but verification by the Director of Nursing confirmed that no staff had received the required training. At the time of the survey, 79 residents were residing in the facility.
Failure to Provide Annual Behavioral Health Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received annual in-service training on behavioral health, as required by facility policy and assessment. Record review showed that the in-service calendar scheduled behavioral health training for all staff in January and behavioral management training in October. However, as verified by the Director of Nursing, no staff received the required annual behavioral health training. This deficiency has the potential to affect all 79 residents currently residing in the facility.
Resident Injury Due to Inadequate Supervision During Repositioning
Penalty
Summary
The facility failed to ensure the safety of a resident during repositioning, resulting in a significant injury. The resident, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Emphysema, and Osteoporosis, sustained a deep leg laceration requiring hospital treatment. The incident occurred when a Certified Nurses Aide (CNA) attempted to recline the resident's wheelchair, causing the resident's leg to become caught on the edge of the bed, leading to a 10.5 cm laceration. The facility's Skin Condition Monitoring policy requires proper monitoring and documentation of skin abnormalities, but there was no documentation of prevention techniques in use for the resident. The CNA involved in the incident did not ensure the resident's legs were clear of obstacles before moving the wheelchair, which directly led to the injury. The CNA was later terminated for poor work performance, including sleeping on the job. Interviews with facility staff revealed that the CNA failed to check the resident's leg position before moving the wheelchair, which was a critical oversight. The Assistant Director of Nursing confirmed that the CNA should have been more vigilant in ensuring the resident's safety. The facility did not have a Quality Assurance form for the newly acquired skin condition, indicating a lapse in following their own procedures for documenting and addressing skin injuries.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer physician-ordered insulin to a resident diagnosed with Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease. This failure was identified through interviews and record reviews, revealing that the resident experienced emotional distress due to not receiving insulin as ordered. The resident expressed fear that the facility's staff might harm him by not administering his insulin correctly. This situation resulted in multiple abnormal laboratory values indicating hyperglycemia. The facility's policies on Adverse Drug Reactions and Medication Discrepancy, as well as Medication Administration, were not adhered to. The resident's Medication Administration Records from May to August showed numerous instances where blood glucose level checks and insulin administrations were not documented. Specifically, there were significant omissions in administering Tresiba, Trulicity, and Lispro insulin, as well as in recording blood glucose levels. These omissions were confirmed by the Assistant Director of Nursing, who stated that blank entries could be interpreted as tasks not completed. The resident's laboratory results further highlighted the issue, with fasting glucose levels consistently high and a Hemoglobin A1C level of 9.3, which was above the physician's target of 8 or below. The physician had ordered a Hemoglobin A1C test based on earlier high glucose levels, but it was not conducted until months later. The physician acknowledged that the lack of insulin administration and routine blood sugar monitoring could have contributed to the elevated Hemoglobin A1C levels.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to serve foods as written on the menu, which has the potential to affect all 63 residents living in the facility. On the specified date, the menu listed Oven Fried Chicken Breast, Mashed Potatoes, Chicken Gravy, Mixed Vegetables, Roll/Margarine, and Pie, but residents were served Plain Baked Chicken, Mashed Potatoes, Carrots, Bread, and Strawberry Pie. The Dietary Manager, V5, was unaware of why the substitutions occurred and mentioned that the frozen mixed vegetables did not arrive, although canned mixed vegetables were available. Additionally, there were frozen rolls in the freezer that could have been used. The Dietary Manager attributed the issue to a new cook who was unfamiliar with the procedures. During a group interview with the Resident Council, several residents complained that the menu often listed items that were not served, and they were given various reasons for the discrepancies, such as delivery issues or the cook's preferences. The facility's substitution book, which is supposed to document all menu changes and be signed off by a Registered Dietitian, had few entries, and the Dietitian had not signed off on the substitutions. An example of an improper substitution was Banana Pudding instead of a serving of fruit, which was not documented correctly in the substitution book.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices, which could potentially affect all 63 residents. Observations revealed that the floor refrigerator designated for resident use emitted a strong sour odor and contained various unlabeled and undated food items, including a cheese package, take-out containers with spoiled chicken, dried spaghetti, and a sandwich dated from the previous month. Additionally, a murky bottle of water with brown lemon slices, a bag of mixed fruits, and several unidentified items in the freezer were found without proper labeling or dating. The Dietary Manager and Director of Nursing confirmed these items should have been discarded and labeled appropriately. In the kitchen, the facility did not adhere to proper sanitation solution preparation. A cook was observed mixing a chlorine solution using a bottle cap instead of a measuring spoon, resulting in a concentration over 200 parts per million, which is considered poisonous. Despite attempts to correct the solution, the concentration remained above the required level. The cook, who had limited English proficiency, was unable to confirm if he routinely checked the chlorine levels or knew the correct concentration. Additionally, food items in the reach-in and walk-in refrigerators were found without labels or dates, including thickened liquids, cheese slices, and sour cream, which the Dietary Manager acknowledged should have been labeled and discarded. Further inspection of the kitchen revealed unsanitary conditions, such as a layer of dust on the interior baffles and a black, greasy dust on the fans above the food preparation area. The steam table contained pre-cooked chicken placed hours before serving, which the cook admitted to doing routinely. The Dietary Manager stated that the chicken only needed to be heated before serving. These findings indicate a lack of adherence to the facility's policies on food storage, sanitation, and preparation, as well as inadequate monitoring and communication among staff.
RN Staffing Deficiency in July 2024
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for eight consecutive hours on four specific days in July 2024. This deficiency was identified through interviews and record reviews, which revealed gaps in the nursing schedule on the weekends of July 6th, 7th, 20th, and 21st. The Assistant Director of Nursing confirmed these gaps in coverage. The facility's assessment plan, dated August 12, 2024, was intended to ensure sufficient staffing to meet resident needs, but the July schedule did not reflect this plan. At the time of the report, 63 residents were residing in the facility, as documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS 671, signed by the Administrator on August 18, 2024.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration for two residents. An LPN was observed preparing and administering medications to a resident without wearing gloves and without performing hand hygiene. The LPN handled various medications directly with bare hands and administered insulin injections without gloves, subsequently touching another resident's medication without sanitizing hands in between. This practice was in direct violation of the facility's policy on standard precautions and medication administration, which mandates the use of gloves and hand hygiene to prevent the spread of microorganisms. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs) among residents. The facility's policy requires the use of gowns and gloves during high-contact care activities for residents with open wounds, indwelling medical devices, or those colonized with MDROs. However, observations revealed that staff were not following these precautions. For instance, a resident with an indwelling urinary catheter did not have EBP signage or personal protective equipment (PPE) available in their room. Another resident with a pressure ulcer did not have appropriate EBP measures in place during care. Interviews with staff indicated a lack of awareness and implementation of EBP throughout the facility. Some staff members were unfamiliar with the concept of Enhanced Barrier Precautions, and there was a noticeable absence of necessary PPE and signage in rooms where it was required. The Assistant Director of Nursing acknowledged the oversight and confirmed that the facility's infection control procedures were not being fully implemented, despite being aware of the requirements.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the facility Ombudsman regarding transfers to the hospital. Specifically, the facility did not provide written notices of transfer to residents R25, R35, R45, and R70, nor did it notify the Ombudsman of these transfers. This deficiency was confirmed through interviews and record reviews, revealing that the Social Services Director and the Administrator acknowledged the lack of notifications. Resident R25 was transferred to a local hospital on two occasions, and R35 was transferred three times, with no evidence of notification in their records. Similarly, R45 was transferred four times without written notice. Resident R70, who had a history of cardiac arrest and respiratory failure, was transferred to the hospital without a written notice or Ombudsman notification. These failures have the potential to affect all 47 residents in the facility.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave, as required by their own policy. This deficiency was identified for four residents, R25, R35, R45, and R70, out of a sample of 47. The facility's Bed Hold Guarantee Policy, revised on 8/1/17, mandates that the resident, their family, or legal representative be given the 'Notice of Bed Hold Policy' at the time of discharge or therapeutic leave, or within 24 hours thereafter. However, the medical records for these residents did not contain documentation of such notice being provided. Specifically, R25 was hospitalized on two occasions, and R35 on three occasions, without receiving the required notice. The Social Services Director confirmed that neither resident nor their representatives were provided with the bed hold policy or a written notice of transfer. Similarly, R45 was transferred to the hospital on four separate occasions without documentation of a bed hold notice. R70, who was transferred to the hospital after experiencing shortness of breath, also did not receive the bed hold policy notice. The facility administrator acknowledged that the policy was not provided to R70 upon transfer.
Failure to Develop Comprehensive Care Plans for Medications and Behaviors
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents regarding their use of anticoagulants and psychotropic medications. Specifically, the care plans for these residents did not address the use of medications such as Eliquis, Aripiprazole, Buspar, Klonopin, Luvox, Remeron, and Sertraline. This oversight was confirmed by the Care Plan Coordinator, who acknowledged the absence of care plans for these medications. Additionally, the facility did not address target behaviors exhibited by one resident, who displayed behaviors such as hoarding, agitation, and self-isolation. The Assistant Director of Nursing confirmed that these behaviors were not documented in the resident's care plan, despite being aware of them. The lack of comprehensive care plans for these residents indicates a failure to meet the facility's policy of assessing and reassessing residents to develop person-centered care plans.
Failure in Controlled Substance Reconciliation
Penalty
Summary
The facility failed to perform the required nurse shift-to-shift controlled substance reconciliation for 19 residents who were receiving controlled substances. The facility's policy mandates that all Schedule II drugs must be counted and reconciled by the nurse coming on duty with the nurse going off duty, and these records should be retained for at least one year. However, a review of the narcotic Shift Change Accountability Record Sheet for Controlled Substances for August 2024 revealed missing nursing documentation for the required reconciliation on specific dates. This was confirmed by a Licensed Practical Nurse and the Director of Nurses, indicating a lapse in adherence to the facility's policy for controlled substance management.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident mental abuse to the state agency, as required by their Abuse Prevention Program policy. The policy mandates that all alleged violations involving mistreatment, neglect, or abuse must be reported immediately to the administrator and other officials in accordance with state law. In this case, a resident, who was cognitively intact, reported that a Licensed Practical Nurse (LPN) would deliberately delay administering medications and laugh about it, causing distress to the resident. The resident communicated these concerns to the Administrator in Training, the Director of Nursing, and the Assistant Director of Nursing, but no report was made to the state agency. The Administrator in Training, who is also the Abuse Coordinator, confirmed that no abuse report was submitted to the state agency despite being informed of the resident's conflicts with the LPN. The Assistant Director of Nursing acknowledged the resident's complaints and stated that there was a personality conflict between the resident and the LPN. The facility's response was to avoid conflict by not assigning the LPN to the resident's hall until the resident was discharged. However, the failure to report the allegation to the state agency constitutes a deficiency in adhering to the facility's abuse reporting policy.
Failure to Remove Accused Employee and Investigate Abuse Allegation
Penalty
Summary
The facility failed to immediately remove an employee accused of mental abuse from resident care and did not complete an abuse investigation for a resident who alleged mistreatment. The facility's policy mandates that employees accused of abuse be immediately removed from resident contact until an investigation is completed. However, in this case, the accused employee, a Licensed Practical Nurse (LPN), was not removed from resident contact after a resident, who was cognitively intact, reported that the LPN was withholding medications and laughing about it, causing distress to the resident. The resident had previously voiced allegations of mistreatment by caregivers, and the care plan required such allegations to be investigated per facility protocol. Despite the resident's complaints and the involvement of the Assistant Director of Nursing (ADON) in addressing the situation, the Administrator in Training, who was also the Abuse Coordinator, did not perceive the situation as abuse and did not conduct a formal investigation or remove the LPN from resident contact. The resident expressed distrust towards the LPN and refused to take medications from her, leading to the ADON administering the medications instead.
Failure to Complete PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) was completed for three residents with mental disorders or intellectual disabilities. Resident 1, who has diagnoses of Schizophrenia and Psychosis, did not have any documentation of a PASARR Level I screening in their medical record. The Assistant Director of Nursing (ADON) confirmed that there was no record of such a screening ever being completed for this resident. Resident 58, admitted with a diagnosis of Schizophrenia, had a PASARR Level I screening indicating the need for further assessment after 60 days. However, the facility did not conduct an additional PASARR screening once the resident's stay exceeded this period. Similarly, Resident 44, diagnosed with Bipolar Disorder and other psychiatric conditions, had no documentation of a PASARR screening in their medical record. The ADON acknowledged the absence of a PASARR for this resident and mentioned that a request for a screen had been made.
Failure to Perform Skin Checks and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician-ordered daily skin checks and scheduled pressure ulcer treatments were completed for three residents, and a pressure ulcer care plan was not developed for one resident. The facility's policies on decubitus care, comprehensive care planning, and pressure sore prevention were not adhered to, leading to deficiencies in care. The Director of Nurses verified missing documentation for daily skin checks, indicating non-compliance with physician orders. One resident with spastic cerebral palsy, malnutrition, epilepsy, and scoliosis had a high risk for pressure ulcers, as indicated by a Braden Scale score of 13. However, 10 out of 17 physician-ordered daily skin checks were not performed. Another resident with a history of bilateral knee amputation, chronic kidney disease, type 1 diabetes mellitus, chronic diastolic heart failure, and depression with anxiety was at moderate risk for pressure ulcers, with a Braden Scale score of 17. For this resident, 3 out of 7 daily skin checks were not completed. A third resident, who was pleasantly confused and had an active left foot lateral pressure injury and a stage three right hip pressure injury, did not have a care plan for pressure ulcers. The resident's treatment administration record showed missed scheduled skin checks and wound treatments. The Licensed Practical Nurse confirmed gaps in documentation and stated that the responsibility for daily treatments lay with the floor staff. The Minimum Data Set/Care Plan coordinator acknowledged the absence of pressure ulcer documentation in the resident's care plan and MDS assessment.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to adhere to its Standard Precautions policy during the care of a resident with a suprapubic catheter. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes while providing catheter care to a resident diagnosed with Neurogenic Bladder and Obstructive Uropathy. The facility's policy mandates handwashing after touching blood, body fluids, secretions, excretions, and contaminated items, and immediately after glove removal to prevent cross-contamination. However, the LPN removed a gauze dressing saturated with bloody drainage from the resident's catheter site, changed gloves without washing hands, and continued with the catheter care. The resident's care plan aimed to prevent urinary infections, yet the LPN acknowledged the oversight in hand hygiene, which is crucial in preventing infections. The resident had a history of urinary tract infections, and a recent urinalysis showed abnormal results with a significant growth of Providencia Stuartii, indicating a potential infection. This incident highlights a breach in infection control practices, which could contribute to the resident's ongoing urinary health issues.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for a resident over a period of six consecutive months. This deficiency was identified for one of the five residents reviewed for unnecessary medications in a sample of 47. According to the facility's Psychotropic Medication Policy, nursing administration is required to meet with the consultant pharmacist monthly to discuss residents who may need or are due for a medication reduction. However, the medical record of the resident in question, as of August 20, 2024, showed no documentation of medication regimen reviews by a licensed pharmacist for the months of March through August 2024. The Director of Nursing confirmed that only one medication regimen review was completed for this resident in February 2024, indicating a lapse in adherence to the facility's policy.
Failure to Document Justification and Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to document a diagnosis and target behaviors to justify the use of antipsychotic medication for three residents, R7, R49, and R60. For R60, there was no documented diagnosis for the use of Seroquel, and the care plan did not reflect the use of antipsychotic medication. Observations and interviews indicated that R60 did not exhibit behaviors warranting such medication, and the Assistant Director of Nursing (ADON) was unaware of any behaviors or diagnosis justifying its use. For R49, although diagnosed with schizophrenia and other mood disorders, there was no documentation of target behaviors or consistent adverse behaviors in the behavior tracking records. The care plan lacked mention of any behavioral interventions, and the ADON confirmed the absence of documented adverse behaviors. Despite being on Clozaril since June 2022, no gradual dose reduction was attempted, contrary to recommendations. R7 was prescribed multiple psychotropic medications, including Aripiprazole, without a recent gradual dose reduction, despite pharmacy recommendations. The behavior tracking records showed minimal occurrences of behaviors, and observations noted R7 as calm and pleasant. The Director of Nursing acknowledged the overdue status of dose reductions and the lack of documented physician responses to pharmacy recommendations.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for a resident, identified as R67, who was admitted with several serious medical conditions, including Acute Hypoxic Respiratory Failure, Diabetic Ketoacidosis, Acute Kidney Injury, Diabetes Mellitus, Dizziness, and Weakness. The physician's orders, dated shortly after admission, required a Complete Metabolic Profile (CMP) and a Complete Blood Count (CBC) to be conducted. However, a review of the resident's medical record a month later revealed that these lab tests had not been performed. The Director of Nurses confirmed the oversight, acknowledging that the staff missed ordering the necessary lab tests for the resident.
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What surveyors actually found near you
We read the 167 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near East Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Hc Of East Peoria | 1.9 mi | — | 0 | 0 |
| Loft Rehab Of East Peoria, The | 1.9 mi | ★★★★★ | 0 | 0 |
| Goldwater Care Peoria Heights | 5.6 mi | ★★★★★ | 28 | 3 |
| Apostolic Christian Skylines | 5.6 mi | ★★★★★ | 0 | 0 |
| Arcadia Care Peoria Heights | 5.8 mi | — | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.